Provider Demographics
NPI:1093184640
Name:MOHAWK VALLEY NUTRITIONAL SERVICES, PLLC
Entity Type:Organization
Organization Name:MOHAWK VALLEY NUTRITIONAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRIYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-732-9368
Mailing Address - Street 1:2600 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-6311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-6311
Practice Address - Country:US
Practice Address - Phone:315-732-9368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-24
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0050941133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty